NRP Algorithm: Neonatal Resuscitation Quick Reference

The neonatal resuscitation algorithm step by step: the first minute, ventilation, the heart-rate thresholds that decide what comes next, compressions, oxygen targets, and the drug and volume figures. Doses are illustrative; your protocol governs.

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The Neonatal Resuscitation Program (NRP) algorithm is the sequence for a newly born infant who does not transition on their own. It is built on one fact that shapes every step: almost every newborn who needs help needs help breathing. Ventilation is the intervention, and most of the algorithm is about doing it well and checking whether it is working.

This is a study reference built on the AHA/AAP 2020 neonatal resuscitation guidelines and the NRP 8th edition algorithm. It is not a protocol. Your local protocols, your program and your medical direction decide what you do, and the figures here are illustrative.

Before the baby is born

If there is time, ask four questions before delivery: what is the expected gestational age, is the amniotic fluid clear, are there additional risk factors, and what is the plan for cord management. The answers decide how many people and how much equipment you want ready. In the field, that means having warm towels, a bulb syringe or suction, a correctly sized mask and bag, and a way to keep the baby warm before you need them.

The first assessment: three questions

At birth, ask whether the baby is term, has good tone, and is breathing or crying. If the answer to all three is yes, the baby stays with the mother. Dry them, put them skin to skin, keep them warm, and keep watching. For a vigorous baby, current guidance favors delaying cord clamping for at least 30 to 60 seconds.

If any answer is no, start the initial steps.

The initial steps and the first minute

Warm and keep the baby warm. The target temperature is 36.5 to 37.5 °C.
Position the airway: on the back, head in a neutral, slightly extended sniffing position.
Clear secretions only if needed. Routine suctioning of a baby who is breathing is not recommended.
Dry and stimulate: rub the back or flick the soles of the feet.

Then reassess breathing and heart rate. The algorithm calls the first sixty seconds the Golden Minute: the initial steps, reassessment and, if needed, the start of ventilation should all happen inside it.

Apneic, gasping, or a heart rate under 100: ventilate

If the baby is not breathing, is gasping, or has a heart rate under 100 after the initial steps, start positive-pressure ventilation (PPV) and put a pulse oximeter on the right hand or wrist. Consider a cardiac monitor, which reads heart rate more reliably than a stethoscope or a pulse in a baby with poor perfusion.

Rate: 40 to 60 breaths per minute.
Start with room air (21% oxygen) at 35 weeks or more, and 21 to 30% below 35 weeks, then adjust to the target saturations below.
The single best sign that ventilation is working is a rising heart rate.

If the baby is breathing but working hard, or stays cyanotic, position and clear the airway, put on the oximeter, give supplemental oxygen as needed, and consider CPAP.

When ventilation is not working: MR SOPA

If the chest is not moving or the heart rate is not rising, fix the ventilation before you do anything else. The corrective steps are taught as MR SOPA:

Ventilation corrective steps
Letter	Step
M	Mask adjustment: reapply the mask for a good seal
R	Reposition the head and neck
S	Suction the mouth, then the nose
O	Open the mouth
P	Pressure: increase it gradually until the chest moves
A	Alternative airway: an endotracheal tube or laryngeal mask

Ventilation that moves the chest is the treatment. A newborn whose heart rate stays low is far more often under-ventilated than in need of compressions or drugs. Work through the corrective steps before escalating.

Heart rate under 60: compressions

Start chest compressions if the heart rate stays under 60 after at least 30 seconds of ventilation that moves the chest. At that point the algorithm recommends an advanced airway if one is not already in place, increases the oxygen to 100%, and calls for a cardiac monitor.

Ratio: 3 compressions to 1 breath.
Rate: 90 compressions and 30 breaths a minute, 120 events in all.
Technique: two thumbs on the lower third of the sternum with the hands encircling the chest.
Depth: about one third of the front-to-back diameter of the chest.
Reassess the heart rate after 60 seconds of coordinated compressions and ventilation.

If the heart rate stays under 60 despite that, the algorithm moves to epinephrine, preferably IV through an umbilical venous catheter or IO, and to volume if blood loss or hypovolemia is suspected. It also asks you to consider a pneumothorax.

Score an Apgar at 1 and 5 minutes, a record of transition rather than a guide to resuscitation

Target pre-ductal oxygen saturations

A healthy newborn takes several minutes to reach adult saturations, so a low reading in the first minutes is expected. Measure pre-ductal saturation from the right hand or wrist.

Target pre-ductal SpO2 after birth
Time after birth	Target SpO2
1 minute	60–65%
2 minutes	65–70%
3 minutes	70–75%
4 minutes	75–80%
5 minutes	80–85%
10 minutes	85–95%

Drug and volume figures

Newly born infant — illustrative weight-based figures, not orders. Confirm against your protocol.

Drug	Dose	Route	Notes
Epinephrine	0.01–0.03 mg/kg	IV/IO	Recommended starting dose 0.02 mg/kg (0.2 mL/kg of the 0.1 mg/mL concentration), range 0.01–0.03 mg/kg (0.1–0.3 mL/kg), followed by a normal saline flush. Repeat every 3–5 minutes if the heart rate stays under 60. Read the concentration on what you are holding.
Epinephrine	0.05–0.1 mg/kg	Endotracheal	That is 0.5–1 mL/kg of the 0.1 mg/mL concentration, only while IV or IO access is being obtained. The endotracheal dose is higher than the IV dose; do not confuse the two. If the response to an endotracheal dose is inadequate, give an IV or IO dose as soon as access is obtained.
Volume (normal saline or O-negative red blood cells)	10 mL/kg	IV/IO over 5–10 minutes	For suspected blood loss or hypovolemia that has not responded to the steps above.

Training aid only. Verify every value against your local protocol and medical direction before acting on it.

A newborn's weight is often a guess in the field. Many services estimate a term newborn and carry the figures for that weight in their protocol. The pediatric weight tool in this library deliberately refuses a neonate, because the formulas it uses are not defined there.

Meconium-stained fluid

A baby born through meconium-stained fluid who is vigorous gets ordinary care. A baby who is not vigorous gets the initial steps and, if needed, ventilation, exactly as any other newborn. Routine intubation to suction the trachea is no longer recommended; suction is for a visibly obstructed airway.

Prehospital realities

You may have one baby, one mother and two providers. Decide early who is caring for which patient, and call for help if both need it.
Heat loss is fast and dangerous. Warm the room or the back of the ambulance, dry the baby, remove wet towels, and cover the head.
A bag that is too big makes it easy to overinflate. Watch the chest, not the bag.
Count the heart rate out loud for the team, because every decision in the algorithm hangs on it.

The short version

Most newborns who need help need help breathing. Ventilation is the intervention.
Warm, position, clear if needed, dry, stimulate, then reassess, all inside the first minute.
Apneic, gasping or a heart rate under 100: ventilate at 40 to 60 a minute and put on an oximeter.
Not improving: fix the ventilation with MR SOPA before anything else.
Under 60 after 30 seconds of ventilation that moves the chest: compressions at 3:1, 100% oxygen.
Still under 60: epinephrine, preferably IV or IO, and volume if hypovolemia is suspected.
Expect low saturations in the first minutes and follow the target table.